Perception of frontal facial images compared with their mirror images: chirality, enantiomorphic discrimination, and relevance to clinical practice

BACKGROUND

What we think we see consists of models constructed in our brains, which may be constrained, limited and perhaps modified at a cerebral level. Patients may view their mirror image differently to how others and the clinical team view them. Understanding potential variations in perception between real and mirror images is important in clinical practice. The aims were to assess differences in self-perception between frontal facial and mirrored photographs, comparing the results with selfie photographs.

METHODS

Facial photographs were taken by one investigator under standardized conditions for preclinical and clinical students. Each student took a selfie photograph at rest and smiling using his/her smartphone. A mirror image was generated for each image. Each student was shown his/her original and mirror image, without being informed which was which. For each pair of images, students were asked to choose which photograph they perceived as more attractive. A set of photographs of a male volunteer was shown to all participants, to choose either the original or mirror image as the more attractive.

RESULTS

Most observers preferred the true image of the volunteer (P < 0.05), which may be evidence that most people prefer the true image of others, which is how they normally view them. Most observers preferred their own original photograph in frontal view at rest and smiling (P < 0.05), but preferred the mirror image of their selfie photograph at rest and smiling (P < 0.05).

CONCLUSIONS

Significant differences in perceptions of attractiveness between true and mirror-reversed frontal and selfie images were found. Observers preferred their image the way they view themselves in a mirror. The selfie is how other people view an individual. If a selfie is flipped horizontally, that is how an individual sees themselves in a mirror. Most observers preferred the mirror image of their selfie, which is how they would view themselves in a mirror.

Fashioned Mucoperichondrial Flap Technique Versus Fishing Line Technique in the Repair of Septal Dislocation: A Prospective Comparative Study

BACKGROUND

A nasal septal dislocation is a common form of septal deviation with many challenges and different surgical techniques for correction.

OBJECTIVE

To assess the efficacy of fashioned mucoperichondrial flap technique versus fishing line technique in the repair of septal dislocation.

METHODS

The study was a prospective comparative cohort study conducted on 88 patients aged above 18 years who have symptomatic mild to moderate caudal septal dislocation spanning the period from June 2021 to June 2022. Preoperatively, all patients were evaluated by the Nasal Obstruction and Septoplasty Effectiveness (NOSE) scale to assess the degree of nasal obstruction. Anterior rhinoscopy and endoscopic examination of the nose were done for every patient to assess the degree of obstruction, whether mild, moderate, or severe. Outcomes included an assessment of both techniques' efficacy in managing nasal obstruction as expressed by the NOSE scale and comparing both techniques regarding the operative and postoperative details.

RESULTS

The current study showed a highly significant improvement in the NOSE scale postoperatively in both groups (P < .00001 for both groups). The mean operative duration for group I was significantly less than that for group II (P < .00001). There was a nonsignificant difference between both groups regarding the postoperative NOSE scale, and postoperative degree of obstruction (P = .066 and .56, respectively). Regarding postoperative complications, there was a nonsignificant difference between both groups except for patient discomfort as assessed 1 week postoperatively. Group II showed significantly more patient discomfort (P = .02), which improved 4 weeks postoperatively.

CONCLUSION

Both techniques presented in this study effectively corrected mild and moderate caudal septal dislocation with significant improvement of nasal obstruction postoperatively. Both techniques produced good esthetic outcomes and were associated with few comparable complications in both groups.

The potential therapeutic effect of platelet-rich plasma in the treatment of post-COVID-19 parosmia

Background

COVID-19-related olfactory dysfunction is an emerging problem with a significant impact on the quality of life of affected individuals. Different lines of treatment have been used with varying results. This study aimed to assess the potential therapeutic effect of PRP in the treatment of post-COVID olfactory dysfunction. This work aimed to assess the potential therapeutic effect of platelet-rich plasma (PRP) in treating post-COVID-19 parosmia. A pilot study was conducted on 60 patients with post-COVID parosmia without responding to a 3-month course of olfactory training, topical corticosteroids, omega-three, vitamin B12, and zinc supplementation. The patients were distributed randomly and equally among 2 groups. The case group was subjected to three PRP injections in the olfactory cleft at 3 weeks intervals. The control group continued the pre-study treatment protocol for 6 weeks. The degree of parosmia was assessed before and after treatment subjectively using a visual analog scale (VAS) from 0 to 10. Reaching 0–1 on the visual analog scale was a complete improvement. The primary outcome was assessing the post-treatment score for parosmia 1 month after the third injection in the case group. The second outcome was the comparison between both groups regarding the degree of improvement 1 month after cessation of treatment.

Results

There was a highly significant improvement in VAS for parosmia (p < 0.00001) in the case group and a significant improvement in VAS for parosmia in the control group (p = P = 0.00148). There was a significant difference between both groups regarding the degree of improvement favoring the case group (p = 0.002).

Conclusion

Platelet-rich plasma injection in the olfactory cleft offers a therapeutic option for treating patients with post-COVID-19 olfactory parosmia who failed to respond to traditional conservative treatment.

Is self-harm among orthodontic patients related to dislike of dentofacial features and oral health-related quality of life?

OBJECTIVES

To investigate the relationship between self-reported self-harm and dislike of dentofacial features and oral health-related quality of life (OHRQoL).

MATERIALS AND METHODS

Anonymous, self-reporting questionnaires were completed by 699 school children (aged 13-14 years), representing over 1% of the age group in Amman, Jordan. Participants were invited from 23 randomly selected schools in 10 educational directorates. OHRQoL was assessed using the Child Perception Questionnaire (CPQ 11-14). Self-harm was assessed using a constructed self-reporting questionnaire. The relationship between OHRQoL and self-harm was assessed and significant findings were identified at probability of α = 0.05.

RESULTS

Over one-quarter of schoolchildren (26.9%, n = 88) admitted self-harming behavior. Self-harm was reported to be due to dislike of dentofacial appearance among 12.9% of participants (n = 90). Higher CPQ 11-14 total scores and individual dimension scores were associated with the presence of self-harm (P < .001). High self-harm incidence was reported among participants who had dentofacial features that affected appearance (P < .001). Among subjects admitting self-harm, the frequency of self-harming behavior ranged from once to over 10 times per year.

CONCLUSIONS

Significant relationships were found between self-harm and dislike of dentofacial features and OHRQoL.

Academic performance of dental students: A randomised trial comparing live, audio recorded and video recorded lectures

OBJECTIVES

To compare the academic performance of 4th-year dental students randomly divided into three learning groups: live lecture, video recorded lecture and audio recorded lecture. To assess students' attitudes towards the three learning methods.

MATERIALS AND METHODS

4th-year undergraduate students, enrolled in the Orthodontics Theory-1 course, were randomised into three groups receiving different teaching methods; video recorded lecture, audio recorded lecture and live lecture. Subjects were asked to answer two open-ended questions. The first was a simple basic knowledge question in which the answer involved transcribing information from the question, while the second required analytical thinking. Students were also asked to complete a questionnaire assessing their attitudes towards the three learning methods.

RESULTS

94 students participated in the study and were randomly allocated to each learning method. There were no significant differences in scores between the 3 study groups when answering the basic knowledge question (P > .05). The mean score for the analytic question was significantly higher for the live lecture and video recorded lecture groups compared to the audio recorded lecture group (P < .05). The majority of students agreed that lectures were an essential part of their learning experience and that lectures allowed interaction between students and lecturer. Two-thirds of students reported that watching a video recorded lecture provided a similar learning experience to attending a live lecture.

CONCLUSION

Video recorded, audio recorded and live lectures were found to be equally effective for providing basic knowledge. Video recorded and live lectures were more effective than audio recorded lecture at assessing higher levels of analytical thinking. Students attending video recorded lecture performed as well as those attending the live lecture.

Evaluation of Serum Total Immunoglobulin E, Interleukin-17 and Pentraxin-3 as Biomarkers for Chronic Rhinosinusitis With Nasal Polyposis

Background

Different biomarkers are detectable in cases of chronic rhinosinusitis with nasal polyposis (CRSwNP) with need for evaluation of their diagnostic and prognostic roles.

Objective

To assess the serum levels of total IgE, interleukin-17 and Pentraxin-3 in patients with CRSwNP and correlate them with the clinical evaluation using Sino-Nasal Outcome Test (SNOT-22), radiological evaluation using Lund – Mackay (LM) computed tomography scan score, and polyposis recurrence.

Methods

This cross-sectional comparative study was carried out on fifty patients with CRSwNP and twenty-five age and gender matched healthy volunteers as control group. Patients were assessed clinically by SNOT-22 and radiologically by LM score. Blood samples of patients and controls were analyzed for serum levels of total immunoglobulin E (IgE), Interleukin-17 (IL-17) and Pentraxin-3 (PTX-3). The correlation between the serum levels of every two markers of the study markers was assessed. The levels of the three biomarkers were correlated with SNOT-22 and LM scores and polyp recurrence with assessment of their sensitivity and specificity to diagnose CRSwNP.

Results

This study showed significantly higher values of the three biomarkers in patients group compared with control group (p < 0.001 for all). There were significant positive correlations between the levels of the three markers and SNOT 22 and LM scores (p < 0.001 for all) and with recurrence of polyposis (p < 0.001, p = 0.005 and p = 0.032 respectively). Agreement (sensitivity and specificity) for these markers to diagnose patient group was statistically significant (p < 0.001 for all). There was a significant positive correlation between every two markers of the study markers.

Conclusion

Serum levels of total IgE, IL-17 and PTX-3 are important biological markers for diagnosis and follow up of cases of CRSwNP with high sensitivity and specificity in detection of such cases. They should be included in the routine laboratory workup for cases of CRSwNP.

Do various degrees of tooth decalcification affect orthodontists', general dentists' and laypersons' ratings of smile esthetics?

OBJECTIVES

To compare the effect of various degrees of decalcification after orthodontic treatment (white spot lesions) on orthodontists', general dentists', and laypersons' ratings of smile esthetics.

MATERIALS AND METHODS

Eight photographs representing incrementally altered tooth decalcification lesions of maxillary anterior teeth ranging from mild to severe were shown randomly to the study participants. Photographs were rated by a matched sample of orthodontists (N = 42), general dentists (N = 52), and laypeople (N = 58). A visual analogue scale (VAS) was used to assess perceptions of smile esthetics.

RESULTS

The three groups of raters could distinguish between different decalcification levels. Raters gave more negative scores as the decalcification level increased.

CONCLUSIONS

The three groups of raters were able to distinguish between various degrees of decalcification lesions. General dentists were the most critical of all groups when rating decalcification lesions.

Does overbite reduction affect smile esthetics?

OBJECTIVES

To compare the effects of two common methods of overbite reduction on smile esthetics.

MATERIALS AND METHODS

A prospective clinical trial was conducted with 32 patients in whom overbite reduction was achieved using a maxillary incisor intrusion arch (18 patients) or flat anterior bite plate (14 patients). Clinical and cephalometric records were compared pretreatment (T1), after overbite reduction (T2), and posttreatment (T3).

RESULTS

Both treatment groups experienced a reduction in overbite and maxillary and mandibular incisor proclination during treatment (T1-T3). The center of resistance of the maxillary incisor and the incisal edge was significantly intruded in the intrusion arch group during overbite reduction (T1-T2). However, most of the intrusion of the center of resistance was lost by the end of treatment (T2-T3). Both treatment groups experienced a reduction in maxillary incisor display and flattening of the smile arc during overbite reduction.

CONCLUSIONS

Both overbite reduction methods caused a decrease in incisor display and flattening of the smile arc. Smiles were improved in some patients by the end of treatment. However, reduction in incisor display persisted. Clinicians should take precautions to prevent negative effects of overbite reduction.

Skeletal malocclusion: a developmental disorder with a life-long morbidity

The likelihood of birth defects in orofacial tissues is high due to the structural and developmental complexity of the face and the susceptibility to intrinsic and extrinsic perturbations. Skeletal malocclusion is caused by the distortion of the proper mandibular and/or maxillary growth during fetal development. Patients with skeletal malocclusion may suffer from dental deformities, bruxism, teeth crowding, trismus, mastication difficulties, breathing obstruction and digestion disturbance if the problem is left untreated. In this review, we focused on skeletal malocclusion that affects 27.9% of the US population with different severity levels. We summarized the prevalence of class I, II and III of malocclusion in different ethnic groups and discussed the most frequent medical disorders associated with skeletal malocclusion. Dental anomalies that lead to malocclusion such as tooth agenesis, crowding, missing teeth and abnormal tooth size are not addressed in this review. We propose a modified version of malocclusion classification for research purposes to exhibit a clear distinction between skeletal vs. dental malocclusion in comparison to Angle’s classification. In addition, we performed a cross-sectional analysis on orthodontic (malocclusion) data through the BigMouth Dental Data Repository to calculate potential association between malocclusion with other medical conditions. In conclusion, this review emphasizes the need to identify genetic and environmental factors that cause or contribute risk to skeletal malocclusion and the possible association with other medical conditions to improve assessment, prognosis and therapeutic approaches.

Development of white spot lesions during orthodontic treatment: perceptions of patients, parents, orthodontists, and general dentists

INTRODUCTION

Despite the many advances to improve the practice of orthodontics, white spot lesions, or decalcifications, remain a common complication in patients with poor oral hygiene. The purpose of this study was to assess the perceptions and level of awareness of patients, parents, orthodontists, and general dentists toward the development of white spot lesions during orthodontic treatment.

METHODS

This was a prospective epidemiologic survey of the perceptions of orthodontic patients (n = 315), parents (n = 279), orthodontists (n = 305), and general dentists (n = 191) regarding the significance, prevention, and treatment of white spot lesions.

RESULTS

All surveyed groups indicated that white spot lesions detracted from the overall appearance of straight teeth, attributed primary responsibility for the prevention of white spot lesions to the patients themselves, and thought that the general dentist should be responsible for treating white spot lesions. Patients regarded themselves as ultimately responsible for the prevention of white spot lesions (P <0.05).

CONCLUSIONS

The patients, parents, orthodontists, and general dentists had similar perceptions regarding the significance, prevention, and treatment of white spot lesions. All groups indicated that patients were the most responsible for the prevention of white spot lesions. Communication among patients, parents, orthodontists, and general dentists needs to improve to decrease the incidence of white spot lesions in the orthodontic population.

Assessment of the relationship between perceptions of dental aesthetics and demand for orthodontic treatment in 10-11 year old school children in Birmingham, UK

OBJECTIVE

To examine the relationship between perceptions of dental aesthetics and demand for orthodontic treatment, and to determine whether the former can be used to predict the latter.

METHOD

A prospective cross sectional epidemiological survey of a random and representative sample of comprehensive primary schools in South Birmingham, UK. Participants were 389 randomly selected school children aged 10-11 years from 7 primary schools in South Birmingham. Their perceptions of dental aesthetics were determined using the Aesthetic Component (AC) of the Index of Orthodontic Treatment Need (IOTN). Demand for treatment was assessed by asking subjects if they wanted treatment with braces to correct their teeth.

RESULTS

Only 2% of subjects assessed their dentition in the "definite need" for orthodontic treatment category. Demand for treatment was significantly greater in girls than boys (49% and 37% respectively, p < 0.05). Total demand (41%) was considerably greater than self assessed aesthetics in the "definite need" and "borderline need" categories combined (14%). Demand was accurately reflected in patients who perceived their dentition as having moderate to severe (AC 6-9) and very mild aesthetic impairment (AC 1).

CONCLUSIONS

Perceptions of dental aesthetics using the AC of IOTN were able to predict demand for orthodontic treatment in patients with malocclusions of moderate to severe (AC 6-9) aesthetic impairment.

Students' attitudes towards an on-line orthodontic learning resource

AIM

The purpose of this study was to develop an online undergraduate orthodontic e-course and assess its success as a learning resource from the students' perspective.

METHODOLOGY

The orthodontic e-course was composed of six main components; modules, photo gallery, clinical consultations, glossary, reading lists and resources. Four undergraduate orthodontic lectures were converted into a web-based format using text, photographs, PowerPoint presentations and animations. The sample was comprised of sixty-four third year undergraduate dental students at Birmingham Dental School, UK. Their average age was 20.7 years (age range: from 20-25 years). A questionnaire was developed to assess; course design, course delivery, course outcome and the potential use of the e-course as a teaching method.

RESULTS

There were no significant difference between genders (P < 0.05). Overall, student responded very positive to positive for course design, course delivery and course outcome. The orthodontic e-course was still seen by most subjects (86%) as an adjunct and not a replacement of the traditional teaching methods. 34.4% of subjects felt that it should be as an optional supplement and 51.6% felt that it should be integrated with the undergraduate orthodontic curriculum. The significance of the program as a learning resource was reported to be the best aspect of the program.

CONCLUSION

Delivery of web-based material in the undergraduate orthodontic curriculum was seen by students as a significant learning resource which supplements traditional learning methods.

Ranking dental aesthetics and thresholds of treatment need: a comparison between patients, parents, and dentists

The aims of the present study were to compare rankings of dental aesthetics and the threshold at which orthodontic treatment would be sought among patients, parents, and dentists. A prospective cross-sectional study was designed to address these aims. The study sample comprised 100 patients and parents and 23 dental specialists. The patients were equally divided between males and females and their mean age was 14.7 years (standard deviation 2.3 years). The aesthetic component (AC) of the Index of Orthodontic Treatment Need (IOTN) represented impairment of dental aesthetics. The 10 numbered photographs of the AC were cut into equal-sized rectangles and subjects were asked to arrange them from 'the one that looks best' to 'the one that looks worst'. The subjects were then presented with the 10 photographs of AC in sequence and asked to identify the cut-off point between 'teeth that need orthodontic treatment' and 'no treatment'. Statistical analysis was undertaken with a Mann-Whitney test. The results showed that median rankings of dental aesthetics were similar among the three groups (P > 0.05). The median ranking of photographs 1, 2, 3, 4, and 10 were identical to the AC of IOTN. The photographs representing IOTN AC 7 and 8 were allocated the same median rank of 7 and AC 5 and 9 were allocated corresponding median ranks of 6 and 8, respectively. There were no significant differences in median cut-off points for treatment need among the three groups of subjects (P > 0.05), indicating that the mean threshold at which treatment would be sought was AC 4.

An index of orthodontic treatment complexity

The aim of the present study was to develop an index specifically for the measurement of treatment complexity. Input factors were directly related to complexity, and the output was a score measuring the degree of treatment complexity. The sample comprised 120 sets of dental casts, 30 for each of the four main malocclusion classes. Sixteen orthodontists graded the study casts for perceived treatment complexity on a six-point scale and then listed, in order of importance, up to three occlusal features which they felt contributed to complexity from a pre-determined list. Multiple regression analysis was used to derive weightings for each occlusal feature, which would reflect the relevant treatment complexity. In order to obtain an overall treatment complexity score for each case, weightings were then multiplied by the corresponding occlusal feature scores and summed. The relationship between treatment complexity scores and perceived complexity was examined using Spearman's ranked correlation coefficient. The regression equation explained 49.5 per cent of the variance in treatment complexity of the whole sample. Regression analysis on the basis of malocclusion produced R (2) values of 90.7 per cent for Class I, 42.6 per cent for Class II division 1, 62.3 per cent for Class II division 2, and 79.5 per cent for Class III malocclusions. The index of orthodontic treatment complexity (IOTC) scores showed a moderate but highly significant association with the orthodontists' perceived complexity assessments (rho = 0.42, P = 0.000). The proposed IOTC shows sufficient promise to warrant further development.

Regional odontodysplasia: a review of the literature and report of a case

We present a rare case of a developmental anomaly called regional odontodysplasia or 'ghost teeth' in an 8.5-year-old Jordanian girl. The anomaly affected both the mandibular primary and permanent incisors, and the canines bilaterally. The maxillary teeth were unaffected. This is the first case of the anomaly to be reported in Jordan. The clinical, radiographic and histological features are reviewed. The management of affected patients is discussed.

The relationship between patient, parent and clinician perceived need and normative orthodontic treatment need

The aim of the present study was to compare patient, parent and clinician perceived need for orthodontic treatment in relation to normative orthodontic treatment need as measured by the Index of Orthodontic Treatment Need (IOTN). A prospective cross-sectional study was designed to address this aim. The sample comprised 103 patients attending the 'new' patient clinic at the Jordan University Hospital. The patients' mean age was 15.3 years (standard deviation 3.8 years); 33 per cent were males and 67 per cent females. One clinician scored the patients' normative orthodontic treatment need using the IOTN, then determined perceived need using a 10 cm visual analogue scale (VAS). The subjects then assessed their own perceived need and aesthetic component (AC) score and the parents carried out similar assessments for their children. All scoring was carried out blind. The parents had the highest average perceived need scores, followed by patient and clinician scores (6.6, 6.1 and 5.4 cm, respectively). A significant difference was found between the parents and the clinician (P < 0.05). When the relationship between perceived need and clinician-measured normative orthodontic treatment need was investigated, significant differences were found with the dental health component (DHC) for all three groups (P < 0.05). Differences between AC and perceived need scores were also significant for the patients and parents, but not for the clinician (P > 0.05). The present study has shown that perceptions of orthodontic treatment need are multifactorial and influenced by elements other than health measures of normative orthodontic treatment need and perceptions of aesthetics.

Cephalometric norms in an Arabic population

AIM

To identify cephalometric norms for a Jordanian population.

DESIGN

A cross sectional study using a sample selected on the basis of a balanced face and a Class I occlusion.

MATERIALS AND METHODS

65 subjects aged 14-17 years were selected from a larger sample on the basis of Class I incisors, a balanced profile and no previous orthodontic treatment. Lateral skull radiographs were digitised directly to produce values for SNA, SNB, ANB, UI/MX, LI/MN, UI/LI, MMPA and LI/A-Pog.

RESULTS

SNA and SNB were very close to the Eastman Standards. MMPA was significantly lower in Jordanians whilst UI/MX and LI/MN were significantly higher. Lower incisors were 4.6 mm further forward in relation to A-Pog in Jordanians.

Orthodontic treatment need in Jordanian school children

OBJECTIVE

To assess the need for orthodontic treatment among Jordanian school children.

RESEARCH DESIGN

The vehicle of this study was the dental health component (DHC) of the index of orthodontic treatment need (IOTN). The examinations were carried out using mouth mirrors and stainless steel rulers. No more than 30 school children were examined at one time to prevent examiner fatigue.

SETTING

Clinical examinations were carried out on the school premises under natural lighting.

PARTICIPANTS

320 10th grade school children aged 14 to 17 years were selected at random to represent the four main areas of Amman as divided by the Ministry of Education in Jordan.

MAIN OUTCOME MEASURES

A 'definite need' for orthodontic treatment was recorded if the patient fell into grades four and five of the IOTN, while grade 3 represented 'borderline need' and grades 2 and 1 'no need' for treatment.

RESULTS

A 'definite need' for treatment was recorded in 28% of children and 22% had 'border line' need on dental health grounds. Three main occlusal features were responsible for allocating children into the former category; severe displacements of more than 4 mm (45%), increased overjet of greater than 6 mm but less than or equal to 9 mm (22%) and impeded eruption of teeth (24%).

CONCLUSIONS

This study has shown that 28% of Amman school children were in need of orthodontic treatment for dental health reasons.

Microvascular soft-tissue coverage and distraction osteosynthesis for lower-extremity salvage

In our attempts to salvage massive lower-extremity injuries, even in the presence of severe peripheral vascular pathology, adequate soft-tissue coverage is no longer a limiting factor due to recent advances in microvascular composite tissue transfer. Restoration of tibial continuity without shortening has emerged as the last obstacle in the formidable task of salvaging lower extremities with grade III B and III C defects. Proposed solutions to this problem include conventional free cancellous bone-grafting applicable to small defects only, vascularized bone grafts, or shortening of the leg with subsequent elongation using the Ilizarov technique. We present our experience with 3 consecutive cases of lower-limb salvage, utilizing a new approach in which microsurgical soft-tissue reconstruction has been combined with bony reconstruction by distraction osteosynthesis. Bone transport by distraction osteosynthesis under a free flap performed while preserving the initial limb length throughout the treatment period proved to be superior to other methods in selected cases and is presented as a new technique for the management of problematic lower-limb injuries.

Local recombinant tissue plasminogen activator (rt-PA) thrombolytic therapy in microvascular surgery

Vascular thrombosis remains a dreaded complication of any microvascular procedure, be it composite tissue transfer or replantation of amputated limbs or parts. Despite the tremendous advances in microvascular-related technologies and the accumulated surgical skills, failures caused by occlusion of anastomosed vessels remain a continuous source of frustration to all microsurgeons alike. Several anticoagulation and antiplatelet protocols have been proposed to be used in conjunction with microvascular surgery. More recently, thrombolytic drugs such as urokinase, streptokinase, and thrombolysin have been introduced, yet their systemic effect on hemostasis remains an undesirable side effect. We present our experience with local intra-arterial, intravenous, and soft-tissue injection of recombinant tissue plasminogen activator rt-PA in replantation surgery in three consecutive patients. Arterial thrombi are managed by intra-arterial rt-PA infusion with the catheter placed proximal to the arterial anastomosis. Venous thrombi are best lysed by infusing rt-PA in an engorged vein of the replanted limb. In replanted digits, direct intravenous infusion is not possible. In such situations, injection of rt-PA in the pulp soft tissues may result in successful salvage. We believe this agent also has a role in microvascular composite tissue transfer in preventing free flap failures as well as in salvaging failing flaps.

An appraisal of the Peer Assessment Rating (PAR) Index and a suggested new weighting system

The PAR Index was developed to measure treatment outcome in orthodontics. Validity was improved by weighting the scores of some components to reflect their relative importance. However, the index still has limitations, principally due to the high weight assigned to overjet. Difficulties also arise from the application of one weighting system to all malocclusions, since occlusal features vary in importance in different classes of malocclusion. The present study examined PAR Index validity using orthodontic consultant assessments as the 'Gold standard' and clinical ranking of occlusal features and statistical modelling to derive a new weighting system, separate for each malocclusion class. Discriminant and regression analyses were used to derive new criteria for measuring treatment outcome. As a result a new and more sensitive method of assessment is suggested which utilizes a combination of point and percentage reductions in PAR scores. This was found to have better correlations with the 'Gold standard' than the PAR nomogram.

Necrotising infection of the orofacial tissues in neonates (noma neonatorum). Case report

Noma neonatorum should be differentiated from noma, in that it is typically a disease of seriously ill premature infants whose birth weight was low, and is caused by Pseudomonas aerugenosa septicaemia. We know of only two case reports of noma neonatorum involving newborn infants born at full term, so we report here another case of noma neonatorum in a neonate born at full term. In addition we describe the differences between noma neonatorum and noma (cancrum oris), a clinically related entity.

Local intravenous thrombolysis with recombinant tissue plasminogen activator for salvage of forearm replantation

Microvascular anastomoses are at risk of thrombosis, especially when repairing avulsed or crushed tissues, or when ischemia time is prolonged. When all surgical techniques to avoid thrombosis of the microanastomoses fail, thrombolytic agents may play a role in dissolving the thrombus and preventing rethrombosis. The authors present a case in which recombinant tissue plasminogen activator (rt-PA) was locally infused to salvage thrombosed venous microanastomoses after replantation of an amputated forearm. They also review the effects of different thrombolytic agents, and emphasize the benefits of rt-PA and its promising role in microsurgery.

Vascularized fascial patch for repair of suboccipital dural defect

Advanced knowledge about cutaneous vascularity has enabled the development of axial flaps such as fasciocutaneous, septocutaneous, and musculocutaneous flaps. It has also laid the foundation for microsurgical free flaps. The newly emerging concept of angiosomes sheds yet more light on the complexity and multiplicity of peripheral blood supply. We describe the use of an extended vertical trapezius flap carrying a segment of latissimus dorsi muscle with the underlying paraspinal fascia to close an infected and irradiated posterior fossa craniectomy and dural defect. This flap illustrates the elevation of an angiosomal block of tissues as an axial flap vascularized by the alternative major blood supply of one of its constituents. The potentials of this "angiosomal flap" are explored. A brief review of dural defect repair is also presented.

Giant cell tumor (osteoclastoma) of the mandible: a diagnostic dilemma and a therapeutic challenge

A recurrent giant cell lesion of bone 4.5 years after initial curettage from the mandibular body is described in a 40-year-old premenopausal female patient. Giant cell tumor is exceedingly rare in this location and histologically may be indistinguishable from giant cell reparative granuloma. The treatment rationale for this particular patient was extrapolated from the treatment of giant cell tumor in other more commonly involved bones. En bloc resection is indicated irrespective of the grade or stage of the tumor, provided satisfactory reconstruction can be achieved. The morbidity from tumor treatment should never, in any case, exceed the morbidity from the tumor itself.

Bacille Calmette-Guérin (BCG)-itis of the hand: a potential hazard for health workers

The bacille Calmette-Guérin vaccine has been used widely for several decades in tuberculosis prophylaxis. More recently, it has been used therapeutically in the management of neoplastic diseases such as malignant melanoma and urinary bladder tumors. Complications of the b. Calmette-Guérin vaccine and therapy are widely reported in the literature. However, its potential hazard to health workers is not well described. We present a case of b. Calmette-Guérinitis on the extensor surface of the left ring finger of a surgical resident following an accidental prick with a contaminated syringe while installing intravesical b. Calmette-Guérin to a patient being treated for a bladder tumor. A brief review of tuberculous hand infection is presented together with its recommended treatment. A review of the various usages of b. Calmette-Guérin is also presented, stressing the various reported complications.

The effects of archwire forces on incisor intrusion

The forces exerted by archwires were measured in association with both Begg and Straight-Wire attachments. Seven stainless steel and three nickel-titanium wires were tested at vertical deflections equivalent to 20, 30, and 40 degrees, these being incorporated via anchor bends or reverse curve of Spee as appropriate to each system. All seven brands of stainless steel arches demonstrated similar performance. An increase in archwire diameter from 0.016 to 0.018 inch increased intrusive forces by 64 per cent for stainless steel and 58 per cent for nickel-titanium. Increasing anchor bend or reverse curve of Spee produced considerable force increases across the range of specimens. Begg archforms produced more force than Straight-Wire archforms of similar deflection when attached to molars only. Attachment of archwires to second premolars in addition to molars reduced the intrusive forces produced by Begg arches, but increased the forces of Straight-Wire arches.